The Evaluation and Measurement of Severity of Challenging Behaviour as part of an Assessment Pathway

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The Evaluation and Measurement of Severity of
Challenging Behaviour as part of an Assessment
Pathway Leading to Multi-Disciplinary Formulation
and Individualised Care Planning Joanne
Sharp,Senior Assistant Psychologist,Prudhoe
Hospital,Northumberland,NE42 5NT
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• There will be time for questions at the end of
  the presentation, but please free to ask
  questions throughout

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Presentation Abstract

• Stephenson House is a national, eight-bed, low
  secure tier-4 unit for young people with a
  learning disability with forensic and mental
  health needs. A multi-disciplinary approach to
  working is adopted throughout practice last year
  we presented evaluation of outcome measures
  within the MDT. A new approach is currently
  being piloted within the unit to give additional
  outcome data in terms of severity ratings
  appertaining to challenging behaviour. This new
  severity measurement demonstrates the severity of
  a persons behavioural presentation allowing us
  to evaluate, over the duration of a persons
  admission, whether this reduces in addition to
  frequency. A case study will be presented to
  illustrate the use of this technique and the
  introduction of evaluation of behavioural
  outbursts.This behavioural evaluation fits into
  the overall assessment pathway. The information
  derived from the behavioural evaluation, along
  with other assessments, is used to provide an
  overall formulation of the young persons
  presentation. Group MDT formulation sessions are
  then held, the efficacy of which evaluated, to
  consolidate information. At this relatively early
  stage, the benefits of this new approach on
  individual care plans are still being evaluated
  but we hope to present some preliminary data.
  With a more appropriately individually-tailored
  care plan in place, and with the behaviours
  better understood, staff around the young person
  are better equipped to proactively work towards
  reducing, or at least managing the young persons
  behaviour.

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Stephenson House
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Presentation Overview

• The service provided at Stephenson House
• Stephenson House Assessment Pathway and MDT
  Formulation
• The Evaluation of Eposodic Severity, in general
  and with specific regard to Stephenson House
• Care Planning including a brief introduction to
  the Stephenson House Triangle of Needs being
  presently piloted.

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Our Service

• Specialist tier four national specialist
  assessment and treatment service for children and
  young people with LD.
• Low secure, eight bed unit situated in three
  hundred acres of parkland in Northumberland.
• 13-19yrs with moderate to borderline learning
  disabilities.
• Highly specialised MDT

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Our Young People

• Typical presenting problems
• communication disorder and/or delay
• challenging behaviour (aggression, sexually or
  socially inappropriate behaviour etc)
• forensic histories
• mental health problems (anxiety, depression,
  psychosis etc)
• attachment difficulties/disorders
• Sensory processing difficulties
• Many of the young people coming to us have
  chaotic histories including abuse, multiple
  care/foster placements and substance misuse.

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Our Young People .....cont

• Involved Agencies
• Police
• Criminal Justice Service
• Social Services
• Probation
• LEA
• Care settings
• Community based professions (OT, Psychology, SALT
  etc)
• Previous/future placement professions
• GP
• Psychiatry
• Respite

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Background to Severity

• Vollmer et al (2000)
• Applied Behavioural Analysis (ABA) uses the
  principles of behavioural psychology and applies
  them to cross-setting human behaviour
• ABA is predominantly based upon Skinners Operant
  Learning Theory (1953)
• Iwata et al (1996)
• ABA has made significant contributions to the
  area of challenging behaviour within the Learning
  Disability Population

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Background to Severity .cont

• LaVinga
• The frequency of challenging behaviour appears to
  be the largest researched DV within the behaviour
  literature
• Not enough attention in the literature paid to
  the measurement of severity
• In the immediate term
• As a management strategy
• As a measure of evaluation over time

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Stephenson House Assessment Pathway (Assessment)
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Stephenson House and Severity

• Why are Severity Ratings important on Stephenson
  House?
• Issues with the quality/depth of evaluation
  information
• Adequate representation of progress
• Facilitation and subsequent evaluation of
  severity management and reduction

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The old way

• Case Study
• A young person within the service was
  approaching discharge. Due to cyclical mental
  health, her challenging behaviour continued to
  occur in conjunction as her mental health dipped.
  The existing method of recording frequency of
  challenging behaviour did not illustrate that
  across her admission, the severity of her
  challenging behaviour had reduced. We were able
  to present severity data which aided discharge to
  a community setting.
• While the data was presented only in terms of
  frequency, it appeared that she may be too high a
  risk to place in the community and thus another
  hospital placement was being considered.

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New way Objectives

• Comprehensive Behavioural Evaluation
• Monitor severity of behaviour in addition to
  frequency
• Aim to reduce severity of behaviour
• Provide more minute information as to behaviour
  for the purpose of risk assessment and management
  and ultimately discharge planning

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Development of the Severity Scale

• The young person in this case study presented
  with outbursts of behaviour so severity is
  attributed to outbursts but the theory can be
  generalised to individual behaviours.
• Compiled adapted recording sheets
• Compiled staff information sheets
• All in collaboration with the young persons
  named nurse.

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Daily Behaviour Recording Chart
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Recordings to Graphs the process

• Nursing Staff fill out the behavioural recording
  form
• From that, Psychology are able to assign a
  severity rating
• Graphs are then created to illustrate the
  information.
• Additional information is also collected such as
  time and duration of the outburst.

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Severity Scale

• Level 1 one typography of outburst
  behaviour occurs
• Level 2 more than one typography occurs
  (not necessarily the same
  behaviour)
• Level 3 minor injury caused by outburst
  behaviour that required no medical aid
  but did leave a mark
• Level 4 injury caused by outburst that required
  first aid or hospital treatment

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Severity of Recorded Behaviours
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Severity Scale Sensitivity

• Over time, it became apparent that the scale we
  had devised was simply not sensitive enough to
  accurately evaluate the young persons behaviour
• A new scale was drafted with greater sensitivity
• This new severity scale was applied
  retrospectively to the data to produce more
  accurately reflective evaluation data

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Sensitive Severity Scale

• Level 1 One occurrence of verbal aggression
  occurs swearing, non-person-directive
  gesturing
• Level 2 Multiple occurrence of a level 1
  behaviour
• Level 3 Physically aggressive gesture to
  people raising fist, squaring up /or
  physical aggression to objects
• Level 4 Physical aggression to self or others
  resulting in no injury

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Sensitive Severity Scale .cont

• Level 5 Physical aggression to self or
  others resulting in injury leaving a
  mark redness, bruise
• Level 6 Physical aggression to self or
  others resulting in injury requiring
  1st Aid
• Level 7 Physical aggression to self or others
  requiring Hospital Attention

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Purpose of Graphing Episodic Severity

• What it shows.
• Allows evaluation of both severity and frequency
  throughout the admission.
• Trends in behaviour
• Can record multiple outbursts of behaviour
• Allows us to evaluate and present progress in
  terms of reduced severity and frequency if
  behaviour/s

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Severity and Frequency of Recorded Behaviours
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Severity and Frequency of Recorded Behaviours

• The benefit of this graph is that it gives an
  overall picture of the outbursts as they are
  occurring throughout admission.
• The problem is that due to the amount of
  information being presented in one space, it can
  be a little overwhelming and bewildering.
• It is therefore helpful to break that information
  down into separate graphs for frequency and
  severity.

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Occurrence of Recorded Behaviours
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Severity of Recorded Behaviours
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Severity of Recorded Behaviours

• The frequency chart is a very simple chart that
  gives basic information as to occurrence.
• The severity chart is more complex, but allows
  for the presentation of far more information the
  monthly range in severity ratings and the
  average.

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Additional Information

• From the additional information collected on the
  daily recording sheet, the following are from a
  selection of additional information graphs
• The hourly frequency chart gives us a better
  picture of occurrence of behaviours within the
  24-hour day. This gives us further evaluation
  ability with regards to the possible
  precipitating factors of the behaviour.
• The duration chart allows for a secondary
  analysis of severity.
• Both of these graphs are produced simply by
  recording the onset and offset of the episode.

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Duration of Recorded Behaviour
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Hourly Frequency of Recorded Behaviours
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Reliability Checking - What is reliability
checking?

• The process of checking data sources against one
  another.
• Daily Behaviour Recording Sheets
• Nursing Notes
• Clinical Team Meeting Reports
• The recording reliability is calculated for each
  month and a percentage attached
• Reliability is then graphed and should improve
  over time

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Reliability Checking Gold Standard

• The Periodic Service Review, LaVigna G.W., et all
  (2003)
• A reliability confidence of 85-90 is to be
  striven for
• However, it is important to be realistic when
  aiming for reliability of data 80 is a
  realistic target

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Reliability Checking - Why is reliability
checking important on Stephenson House?

• We have noticed that on occasion, an incident
  would be discussed at a CTM, or may be recorded
  in the nursing notes, but has not appeared on the
  daily behaviour recording sheets and visa-versa
• A lack of reliability of any measure results in
  the data presented from that measure lacking power

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Reliability Checking
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Evaluation of Severity Scaling The Positives

• More accurate data
• A useful forum for nursing assistants to make
  suggestions and note antecedents or management
  strategies
• Involving staff in Functional Analysis
• Spotlight effect focusing on a particular
  behaviour can lead to a heightened awareness and
  interest of that behaviour which ultimately leads
  to better and more accurate recordings and
  evaluation
• Better staff reflection
• Highly individualised
• Raises issues, for example, the need for a more
  sensitive measure

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Evaluation of Severity Scaling The
Negatives/Difficulties

• Demand on resources
• Nursing Assistants - completing more detailed
  recording forms
• Psychology time a more detailed evaluation
  process rating, graphing, reliability checking
• Making changes to the way people work can be
  difficult to communicate and implement
  effectively
• Would ideally require staff training prior to the
  implementation of the severity rating

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Evaluation of Severity ScalingStaff Reflections
Named Nurse

• There are two main aspects of the scaling of
  episodic severity that I feel are of particular
  benefit and they are 1) The severity scaling
  promotes more reflective, person centred
  practice recording can be targeted to the
  individuals needs, thus better informing
  practice,
• 2) recordings, of any nature, are only as
  useful as they are accurate. The practice of
  checking reliability highlights any recording
  problems which can then be quickly addressed and
  improved upon.

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Evaluation of Severity ScalingStaff Reflections
Nursing Assistant

• The rating of severity is definitely a good
  thing and the actual recordings take no longer
  than recording frequency alone. Nursing
  Assistants can use the forms to make suggestions
  direct to Psychology and can then see those
  suggestions are being considered and used.
  Regular feedback as to the graphed recordings
  would be helpful in that it would improve
  knowledge and understanding of behavioural
  patterns which aids understanding as to the
  benefit of the recordings. I think this would
  lead to better and more accurate recordings

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Evaluation of Severity Scaling Feedback Process

• The involvement of staff, and indeed their
  perception of their own involvement is key to the
  success of this process, as a result the
  following feedback approaches are being
  operationalised
• Staff board notices
• Reliability graphs
• Comments as to the additional information that
  people have been providing and encouragement for
  this to further develop
• Encouragement for the inclusion of information
  which historically has been lees reliable, to be
  recorded and the benefit of this
• Overall a big Thank You for their involvement
• Face-to-Face
• Asking questions as to the process
• Asking for suggestions as to improvements
• Graphed Behaviours
• Reliability

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Stephenson House Assessment Pathway (Formulation)
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Process of Multi-Disciplinary Formulation

• Weekly CTMs
• Core Group prior to initial and the subsequent
  quarterly CPAs
• Using the 5-P model of formulation
• Presenting Problems
• Precipitating Factors
• Perpetuating Factors
• Predisposing Factors
• Protective Factors

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Incorporating Formulation

• Informs
• further assessment and therapeutic needs
• Care Planning
• Discharge Planning

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Stephenson House Assessment Pathway
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Stephenson House Triangle of Care Needs Formation

• Currently being piloted within Stephenson House
  (more details on the effectiveness of this
  approach could be presented next year)
• MDT developed a triangle of care needs for use on
  Stephenson House when developing Individual Care
  Plans
• Developed using several existing models
• Every Child Matters
• Maslows Hierarchy of Needs (Maslow, A.H., (1970)

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Stephenson House Triangle of Care Needs
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Linking everything together

• The evaluation of severity work for this young
  person fits into the safety element of the
  triangle
• Managing Violence and Aggression plan based upon
  the evaluation work done
• This in turn, is influencing therapeutic
  interventions
• Behavioural reward plans as a focussed support
  strategy

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• Question Time!

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Please feel free to contact me on

• Joanne Sharp,Senior Assistant Psychologist,Prudh
  oe Hospital,Northumberland,NE42 5NT
• Joanne.Sharp2_at_ntw.nhs.uk
• 01661 51 4412

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References

• Iwata, B.A., Bailey, J.S., Neef, N.A., Wacker,
  D.P., Repp, A.C., Shook, G.L. (Eds.). (1996)
  Behaviour analysis in developmental disabilities
  (3rd ed.) Journal of Applied Behaviour Analysis
  Reprint Series 1.
• LaVigna, G.W., Willis, T.J. (2005) Episodic
  Severity An overlooked dependent variable in the
  application of behaviour analysis to challenging
  behaviour. Journal of Positive Behaviour
  Interventions.
• LaVigna, G.W., Willis, T.J., Shaull, J.F., Abedi,
  M., Sweitzer. M. (2003) The Periodic Service
  Review A Total Quality Assurance System for
  Human Services and Education. 3rd Edition. Paul.
  H . Brookes Publishing Co.

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References

• Maslow, Abraham, H. (1970) Motivation and
  personality. 2nd Edition. New York, Harper and
  Row.
• Skinner, B.F. (1953) Science and human behaviour.
  New York. Macmillan.
• Vollmer, T.R., Iwata, B.A., Cuvo, A.J., Heward,
  w.l., Mitzenberger, r.g., Neef, N.A (Eds.).
  (2000) Behaviour analysis Applications and
  extensions (1968-1999). Journal of Applied
  Behaviour Analysis Reprint Series 5.